1. Labor and Delivery
CAPT Mike Hughey, MC, USNR

2. Labor
Regular, frequent, leading to progressive cervical effacement and dilatation
Braxton-Hicks contractions
May be painful and regular, but usually are not
Do not lead to cervical change
Labor diagnosis usually made in retrospect.
Cause of labor is unknown

3. Latent Phase Labor <4 cm dilated
Contractions may or may not be painful
Dilate very slowly
Can talk or laugh through contractions
May last days or longer
May be treated with sedation, hydration, ambulation, rest, or pitocin

4. Active Phase Labor At least 4 cm dilated
Regular, frequent, usually painful contractions
Dilate at least cm/hr
Are not comfortable with talking or laughing during their contractions

5. Progress of Labor Lasts about 12-14 hours (first baby)
Lasts about 6-8 hours (subsequent babies)
Considerable variation.
Effacement (thinning)
Dilatation (opening)
Descent (progress through the birth canal)

6. Descent Fetal head descends through the birth canal
Defined relative to the ischial spines
0 station = top of head at the spines (fully engaged)
+2 station = 2 cm past (below) the ischial spines

7. Cardinal Movements of Labor
Engagement (0 Station)
Descent
Flexion (fetal head flexed against the chest)
Internal rotation (fetal head rotates from transverse to anterior
Extension (head extends with crowning)
External rotation (head returns to its’ transverse orientation)
Expulsion (shoulders and torso of the baby are delivered)

8. Watch a Delivery

9. Placental Separation Signs of separation:
Increased bleeding
Lengthening of the cord
Uterus rises, becoming globular instead of discoid
Uterus enlarges, approaching the umbilicus
Normally separates within a few minutes after delivery

10. Initial Labor Management
Risk assessment
Contractions: frequency, duration, onset
Membranes: Ruptured, intact
Status of cervix: dilatation, effacement, station
Position of the fetus: vertex, transverse lie, breech
Fetal status: fetal heart rate, EFM

11. Cervix Dilatation: How far has the cervix opened (in cm)
Effacement: How thin is the cervix (in cm or %)

12. Status of Membranes
Nitrazine paper turns blue in the presence of alkaline amniotic fluid (“nitrazine positive”)
Vaginal secretions are nitrazine negative (yellow) because of their acidity
Pooling of amniotic fluid in the vaginal vault is a reliable sign

13. Orientation of Fetus Vertex, breech or transverse lie
Palpate vaginally
Leopold’s Maneuvers

14. Management of Early Labor
Ambulation OK with intact membranes
If in bed, lie on one side or the other…not flat on her back
Check vital signs every 4 hours
NPO except ice chips or small sips of water

15. Monitor the Fetal Heart
During early labor, for low risk patients, note the fetal heart rate every 1-2 hours.
During active labor, evaluate the fetal heart every 30 minutes
Normal FHR is BPM
Persistent tachycardia (>160) or bradycardia (<120, particularly <100) is of concern

16. Electronic Fetal Monitors
Continuously records the instantaneous fetal heart rate and uterine contractions
Patterns are of clinical significance.
Use in high-risk patients.
Use in low-risk patients optional

17. Normal Patterns Normal rate Short term variability (3-5 BPM)
Long term variability (15 BPM above baseline, lasting seconds or longer)
Contractions every 2-3 minutes, lasting about 60 seconds

18. Tachycardia >160 BPM Most are not suggestive of fetal jeopardy
Associated with:
Fever, Chorioamnionitis
Maternal hypothyroidism
Drugs (tocolytics, etc.)
Fetal hypoxia
Fetal anemia
Fetal arrythmia

19. Bradycardia Sustained <120 BPM
Most are caused by increased in vagal tone
Mild bradycardia (80-90) with retention of variability is common during 2nd stage of labor
<80 BPM with loss of BTBV may indicate fetal distress

20. Late Decelerations
Repetive, non-remediable slowings of the fetal heartbeat toward the end of the contraction cycle
Reflect utero-placental insufficiency

21. Early Decelerations
Periodic slowing of the FHR, synchronized with contractions
Rarely more than BPM below the baseline
Innocent
Associated with fetal head compression

22. Variable Decelerations
Variable in onset, duration and depth
May occur with contractions or between them
Sudden onset/recovery
Increased vagal tone, usually due to some degree of cord compression

23. Severe Variable Decelerations
Below 60 BPM for at least 60 seconds
If persistent, can be threatening to fetal well-being, with progressive acidosis

24. Prolonged Decelerations
Last > 60 seconds
Occur in isolation
Associated with:
Maternal hypotension
Epidural
Paracervical block
Tetanic contractions
Umbilical cord prolapse

25. Pain Relief Narcotics Continuous Lumbar Epidural Paracervical Block
50/50 nitrous/oxygen
Psychoprophylaxis (Lamaze breathing)
Hypnosis

26. Anesthesia During Delivery
Local
Pudendal Block
Epidural
Caudal
Spinal
50/50 nitrous/oxygen

27. Episiotomy Avoids lacerations
Provides more room for obstetrical maneuvers
Shortens the 2nd Stage Labor
Midline associated with greater risk of rectal lacerations, but heals faster
Many women don’t need them.

28. Clamp and Cut the Cord Clamp about an inch from the baby’s abdomen
Use any available instruments or usable material
Check the cord for 3-vessels, 2 small arteries and one larger vein

29. Inspect the Placenta Make sure it is complete Look for missing pieces
Look for malformations
Look for areas of adherent blood clot